Background
Methods
Criteria for inclusion
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Participants: ≥3 adults diagnosed with any type/stage of dementia or mild cognitive impairment (MCI) or where the mean Mini Mental State Examination (MMSE) score plus one standard deviation was ≤26, in any setting.
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Duration: ≥5 consecutive days.
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Interventions: aimed to modify food and/or drink, provide food- or drink-based supplements, assist with eating or drinking or manage swallowing problems (pharmacological and pill-based supplements were excluded).
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Outcomes: nutrition or hydration status [22]; quantity, quality or adequacy of food or fluid intake, ability to eat independently, swallow without aspirating, enjoyment of food or drink or meaningful activity (activity around food or drink that is personally fulfilling, that people enjoy, look forward to or find important). Note - studies were only included if they collected at least one of these outcomes, but where studies were included we also extracted, and report, data provided on the following outcomes: quality of life, functional or cognitive status, views or attitudes, cost effectiveness, resource use, mortality and health outcomes.
Search strategy
Study selection and data collection
Data synthesis
Area | Questions from lay stakeholders | Review findings |
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Type of dementia
| For people with different types of dementia (Alzheimer’s, vascular, dementia with Lewy bodies, other types or mixed types), what interventions can help to maintain or improve food intake or nutritional status and fluid intake or hydration status? | Less than half of studies indicated type of dementia of participants, but most that did enrolled people with AD. Results of 8 ONS studies including AD patients were not consistent - some studies reported improvement in nutritional status or intake, others no effect. Studies of other interventions were too few to compare or inform conclusions. |
Stage of dementia
| What interventions can help to maintain or improve food intake or nutritional status and fluid intake or hydration status in people with mild cognitive impairment, mild/moderate/severe dementia? | Less than half of the studies had any data on stage of dementia of participants. Potential interventions are shown in Table 4, but in studies of people with mild, moderate and/or severe dementia oral nutritional supplements (ONS) improved one or more markers of nutritional status (though usually not all markers, and only over short periods of time). Three studies of fruit juice supplements in people with mild cognitive impairment showed little effect. Shared mealtimes with staff and a commercial lyophilised food also appeared to improve some markers of nutritional status in people with severe dementia, while social interventions (supporting social interactions around food and drink) appeared to improve measures of participation, interactions, happiness, autonomy and involvement in people with mild, moderate and severe dementia. |
Setting
| 1. For people with dementia living in residential care or residing in a medical setting, what interventions can help to maintain or improve food intake or nutritional status and fluid intake or hydration status? 2. For people with dementia living in their own homes with or without a carer (full-time or occasional; close relative or paid carer), what interventions can help to maintain or improve food intake or nutritional status and fluid intake or hydration status? | Most of the studies were conducted in various residential or nursing settings, and very few in participants own homes. Generally, effectiveness of interventions related to the effectiveness of interventions in residential settings. |
Emotional and social issues
| For people with dementia, does emotional closeness of the carer (e.g. close relative vs paid carer) affect the outcomes? | Emotional closeness to the carer was not ever reported in studies, and carers generally appeared to be professional rather than family carers. |
Meaningful Activity
| 1. For people with dementia, what interventions aimed at improving or maintaining food and/or fluid intake, nutrition or hydration status, support meaningful activity (activity around food or drink that is personally fulfilling, that people enjoy, look forward to or find important)? 2. For people with dementia, are there any interventions that decrease food or fluid intake, diminish enjoyment or quality of life, or diminish meaningful activity or social inclusion? | Few studies measured quality of life or happiness using a validated scale. However, some studies especially those with a strong social element (see main review) reported improved autonomy, involvement and interest of participants. Few interventions reported diminished intake or any poorer outcomes, except for a study that gave supplemental yogurt at breakfast, which resulted in reduced weight (possibly as the result of replacing rather than supplementing usual food) |
Individualised interventions
| Do individualised interventions appear more effective than those that are not individualised, in helping people with dementia to maintain or improve food and/or drink intake, nutrition or hydration status (or related outcomes)? | Studies of ONS did not offer individualised interventions (based on needs and preferences of participants) beyond a choice of flavours, but the one study of individualised snacks did not suggest they were helpful. Multicomponent individualised interventions were more positive, suggesting useful effects on some nutritional outcomes. Individualised dysphagia diet and a multicomponent food modification diet appeared to improve weight, and individualised eating assistance was not clearly helpful. |
Interventions around swallowing and oral hygiene
| 1. Do interventions to assess swallowing (and where necessary treat swallowing problems) have any effect on food or drink intake, nutrition or hydration status (or related outcomes)? 2. Do interventions to improve oral hygiene have any effect on food or drink intake, nutrition or hydration status (or related outcomes)? | Studies assessing interventions for swallowing problems were generally inconclusive except that individual and multicomponent interventions including food modification appeared helpful in supporting nutritional status in several studies. No interventions aimed to improve oral hygiene. |
Interventions in acute illness
| Are there any interventions that are particularly effective in helping people with dementia to maintain or improve food and/or drink intake, nutrition or hydration status (or related outcomes) during periods of acute illness? | Only one study included people with acute illness. It provided ONS during acute illness and reported no change in nutritional status [52]. |
Results
Study | Design | Setting, supplement type | Number completed | Dementia stage | Dementia type | Effect on nutrition or hydration status | Effect on intake of nutrients or fluid | Quality and Other outcomes | Duration |
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ONS (including energy, protein and often other nutrients) plus usual food vs. usual food (with or without placebo ONS) | |||||||||
Abalan 1992 France [30] | RCT | Geriatric inpatients. Proprietary ONS (‘Tonexis’) vs usual food | I = 15 C = 14 | NR | AD | N/A | → E intake | ↑ Cognitive function | 15 weeks |
Beck 2002 Denmark [32] | RCT | Nursing home (risk of malnourishment). Home-made ONS vs usual food | I = 8 C = 8 | NR | NR | → Weight | → E intake | N/A | 2 months |
Carlsson 2009 Sweden [34] | CCT (BA) | Group-living facilities for people with dementia. Drinkable yogurt | 13 | NR | Mixed | ↓ Weight | → E intake → Fluid intake | → Functional status | 6 months |
Carver 1995 UK [36] | RCT | Psychiatric hospital/elderly ward (under-weight). Proprietary ONS (‘Fortisip’) vs placebo | I = 20 C = 20 | NR | NR | ↑ Weight ↑* BMI →TSF ↑ MAMC | N/A | N/A | 12 weeks |
de Sousa 2012 Portugal [37] | RCT | Psychiatric hospital, geriatric unit, mild dementia patients (malnourished). ONS vs usual care & advice | I = 20 C = 15 | Mild | AD | ↑ Weight ↑ BMI | ↓ Nutritional risk | → Functional status → Cognitive function | 3 weeks |
Faxen-Irving 2002 Sweden [38] | CCT | Group-living for people with dementia. ONS & diet advice vs usual care | I = 21 C = 12 | Mixed | Mixed | ↑a Weight ↑a BMI ↑‡ TSF → AMC | N/A | → ADL ↓ Cognitive function | 5 months |
RCT | Nursing home (long term rehabilitation centre). ONS vs placebo | I = 24 C = 26 | NR | NR |
↑ Weight
↑ BMI → MAMA → TBW | → E intake → Fluid intake | →Functional status | 10 weeks | |
RCT | Residential care facilities. Protein-enriched drink (+/− exercise) vs placebo drink (+/− exercise) | I = 96 C = 95 | NR | NR | → Weight → ICW | N/A | → Balance → Gait → Lower limb strength | 3 months | |
Gregorio 2003 Spain [40] | RCT | Nursing home residents with AD. Proprietary ONS (‘Nutrison’) vs usual food | IG = 24 C = 74 | Mod | AD |
↑* BMI |
↓* Nutritional risk | N/A | 12 months |
Lauque 2000 France [44] | RCT | Nursing homes (risk of malnourishment). Proprietary ONS (Clinutren, Nestle) vs usual food | I = 19 C = 22 | NR | NR | → Weight → BMI | ↑ E intake ↑ Protein intake | → Grip strength | 2 months |
Lauque 2004 France [45] | RCT | Geriatric wards & day centres (risk of malnourishment). Proprietary ONS (Clinutren) vs usual food | I = 37 C = 43 | Mod | NR |
↑ Weight
↑ BMI | ↑ E intake
↓ Nutritional risk | →ADL → Cognitive function → Eating behaviour | 3 months |
Manders 2009 Netherlands [46] | RCT | Nursing homes. ONS vs placebo | I = 78 C = 33 | NR | NR |
↑ Weight ↑ Calf circumference | N/A | → Functional status → Grip strength → Cognitive status | 24 weeks |
Navrátilová 2007 Czech Republic [47] | RCT | Institutionalised residents with AD (type of institution unclear). Proprietary ONS (‘Nutridrink’) vs usual food | I = 50 C = 50 | NR | AD | → Weight → BMI | ↑† E intake ↑† Protein intake |
↑ Cognitive function | 1 year |
Pivi 2011 Brazil [55] | RCT | Setting unclear. Proprietary supplement (Ensure with FOS®) vs usual care | I = 26 C = 27 | Mild-severe | AD |
↑* Weight
↑* BMI
↑* AMC
↑* AC → TSF | N/A | N/A | 6 months |
Planas 2004 Spain [48] | CCT (BA)♣
| Dementia care day centre. ONS +/− micronutrients | I = 23 C = 21 | Mild | AD | → BMI ↑ MAMC ↑ TSF | ↑ E intake | → Cognitive function | 6 months |
Simmons 2010a USA [50] | RCT | Long-term care facilities, type unclear. Between meal nutritional supplements vs. usual care | I = 18 C = 20 | NR | NR | → Weight | → E intake | ↑ Costs & staff time | 6 weeks |
Souvenir I | CCT (BA)♣
| AD Treatment Centres. Proprietary ONS (Souvenaid) vs isocaloric placebo | I = 98 C = 97 | Mild | AD | → BMI | N/A | → Cognitive function → QoL | 12 & 24 weeks |
RCT | Nursing home (risk of malnutrition). ONS vs usual care | I = 45 C = 42 | Mod-severe | NR | ↑ Weight → BMI ↑ UAC ↑ Calf circumference | → E intake → Protein intake → Nutritional risk | → Cognitive function → ADL | 12 weeks | |
Wouters-Wesseling 2002 Netherlands [53] | RCT | Nursing homes, residents with dementia. ONS vs placebo | I = 19 C = 16 | NR | Mixed | ↑ Weight → BMI | N/A | → Functional status | 12 weeks |
Wouters-Wesseling 2006 Netherlands [52] | RCT | Psychogeriatric nursing homes (with acute infection). ONS vs usual care | I = 18 C = 16 | NR | NR | → Weight → TST → AMC | → E intake | → Functional status | 5 weeks |
RCT | Dementia units within a nursing home. ONS vs high carbohydrate meals | I = 15 C = 19 | NR | AD | ↑ Weight | ↑ E intake ↑ Protein intake | N/A | 3 weeks | |
Fruit juice plus normal food vs control drink plus normal food | |||||||||
Krikorian 2010a USA [42] | RCT | Community-dwelling. Grape juice vs placebo | I = 5 C = 7 | MCI | N/A | →* Weight →* Waist | N/A | ↑ Learning, → Spatial awareness, → Recall | 12 weeks |
Krikorian 2010b USA [43] | CCT | Community-dwelling. Blueberry juice vs placebo | I = 9 C = 7 | MCI | N/A | →* Weight →* Waist | N/A | ? Cognition, ? Spatial awareness | 12 weeks |
Krikorian 2012 USA [41] | RCT | Community-dwelling. Grape juice vs placebo | I = 10 C = 11 | MCI | N/A | → Weight → Waist | N/A | NR | 16 weeks |
Additional snacks between meals plus usual food vs usual food | |||||||||
Simmons 2010b USA [50] | RCT | Long-term care facilities. Between meal snacks & assistance vs usual care | I = 25 C = 20 | NR | NR | → Weight | → E intake | ↑ Costs ↑ Staff time | 6 weeks |
Multicomponent interventions including ONS | |||||||||
RCT | Elderly nursing home residents. ONS, Gratin diet, exercise, oral care vs usual care | I = 54 C = 55 | NR | NR | ↑ Weight ↑ BMI | → E intake ↑ Protein intake | → Cognitive performance → ADL | 11 weeks | |
Boffelli 2004 Italy [33] | CCT (BA) | Malnourished residents of dementia unit. Individualised diet including mealtime assistance, environmental modification and ONS if required | 19 | Severe | Mixed | → Weight → BMI ↑ Serum albumin | N/A | N/A | 18 months |
Study | Design | Setting, Intervention type | No. | Dementia stage | Dementia type | Effect on Nutrition / hydration status | Intake effect | Quality & other outcomes | Duration |
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Swallowing interventions | |||||||||
Bautmans 2008 Belgium [56] | RCT | Nursing home. Cervical spine mobilization to help dysphagia | 15 | Severe | AD | NR | NR | ↑ Dysphagia limit | 1 week |
Germain 2006 Canada [57] | RCT | Long term care facility. Dysphagia diet | I = 8 C = 9 | NR | AD & others | ↑ Weight | ↑ E intake | NR | 12 weeks |
RCT | Hospitals & nursing homes. 1. Nectar-thick or 2. Honey-thick consistency fluids 3. Chin-tuck position | Nectar 133, Honey 123, Chin-tuck 259 | Various | NR | NR | → Aspiration pneumonia incidence (for thickened vs chin-tuck) | 3 months | ||
Food modification | |||||||||
RCT | Elderly nursing home residents. ONS, Gratin diet, swallowing problem management, exercise and oral care vs usual care | I = 54 C = 55 | NR | NR |
↑ BMI ↑ Weight | → E-intake ↑ Protein intake | → Cognitive performance → ADL | 11 weeks | |
Boffelli 2004 Italy [33] | CCT (BA) | Dementia unit. Diet & environment modification, feeding assistance and supplements | 29 | Severe | Various | → BMI → weight ↑ Albumin | NR | NR | 18 months |
Jean 1997 USA [59] | CCT (BA) | Nursing home. Finger food menu | 12 | NR | AD & others | ? Weight loss arrest | NR | ? Eating independence | 6 months |
CCT | Long term care facilities. Individualised food service, food modification, education and dietitian time | I = 33 C = 49 | NR | AD & others | ↑ weight | NR | NR | 21 months | |
RCT | 6 Care homes. Dining environment & menu changes | I = 57, C = 48 | NR | NR | → Weight, → BMI, → Hydrated | NR | → Enjoyment of food/drink | 1 year | |
Salas-Salvado 2005 Spain [61] | RCT | Geriatric institutions. Meal replacement with commercial lyophilised supplement | I = 15 C = 23 | Severe | AD | ↑ Weight ↑ Serum albumin | → E intake → Nutritional risk | → Eating behaviour → Mortality → Cognitive parameters | 3 months |
Soltesz 1995 USA [60] | CCT (BA) | Alzheimer’s Care Centre. Finger food provision | 43 | NR | AD | → Weight | ↑ Proportion food eaten | NR | 6 months |
RCT | Nursing home. High CHO dinners | I = 15 C 19 | NR | AD | NR | ↑ E intake | NR | 21 days | |
Eating or drinking assistance interventions | |||||||||
Boffelli 2004 Italy [33] | CCT (BA) | Dementia unit, diet & environment modification, feeding assistance and supplements | 29 | Severe | Various | → BMI → Weight ↑ Albumin | NR | NR | 18 months |
CCT | Nursing Homes. Staff assistance, prompting, food/drink service and exercise | I = 48 C = 15 | NR | NR | → Serum osmolality → BUN: creatinine ratio | → Food & fluid intake | NR | 32 weeks | |
Simmons 2008 USA [66] | RCT | Skilled nursing homes. Either meal time or between meal feeding assistance | I = 35 C = 34 | NR | NR |
? BMI, ? Weight |
↑ E intake | NR | 24 weeks |
Simmons 2010a USA [50] | RCT | Long-term care facilities. Between meal supplements & assistance vs usual care | I1 = 18 C 20 | NR | NR | → Weight | → E intake | NR | 6 weeks |
Simmons 2010b USA [50] | RCT | Long-term care facilities. Between meal snacks & assistance vs usual care | I2 = 25 C = 20 | NR | NR | →Weight | → E intake | NR | 6 weeks |
Wong 2008 New Zealand [67] | CCT (BA) | Short stay assessment unit.Individual mealtime assistance | 7 | NR | NR |
↑ BMI |
↑ E intake | NR | 12 weeks |
Studies with a strong social element around eating/drinking | |||||||||
Altus 2002 USA [68] | CCT (BA) | Locked dementia unit. Family-style meals −/+ staff training | 5 | Mod- severe | AD & others | NR | NR | ? Resident Participation in mealtime tasks ? Appropriate communication ? Praise statements ? Staff satisfaction with resident participation | 5 days each period |
Charras 2010 France [69] | CCT | Dementia units in nursing homes. Shared mealtime with staff | I = 8 C = 10 | Severe | AD |
↑ Weight | NR | ? Autonomy ? Quality of interactions ? Food quality | 6 months |
Huang 2009 Taiwan [70] | CCT (BA) | Older person care facility, Reminiscence cooking therapy | 12 | Mild-mod | NR | NR | NR | → MMSE ↑ Happiness → Communication ? Participation | 8 weeks |
Santo Pietro 1998 USA [71] | CCT | Dementia unit within a nursing home. Breakfast club (communication therapy) | I = 20 C = 20 | Mild-mod | AD | NR | NR | ↑ Interest & involvement ↑ Communication | 12 weeks |
Oral nutrition supplement (ONS) interventions
Effects of ONS
Effects of interventions for swallowing problems
Supplementary fruit juice
Effects of food and drink modification
Additional snacks between meals
Effects of eating and drinking assistance
Multicomponent interventions including ONS
Effects of interventions with a strong social element around eating and drinking
Effects of interventions for swallowing problems
Effects of food and drink modification
Finger foods
Other food modification
Food modification as part of multi-component interventions
Effects of eating and drinking assistance
Effects of interventions with a strong social element around eating and drinking
Answers to questions from lay stakeholders
Discussion
Aim | Potential interventions (presently unproven) which warrant early reassessment |
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Increase weight and/or BMI | o ONS, gratin diet for those with swallowing problems, plus exercise and oral care (Beck) [31]o Dysphagia diet (reformed minced and pureed foods and thickened fluids) for those with swallowing problems (Germain) [57]o Meal replacement with commercial lyophilised supplement (Salas-Salvado) [61]o Multifactorial intervention including enhanced menu, individualised food service, more dietetic time, increased nutritional awareness and communication (Keller) [63]o Individual mealtime assistance (Wong) [67]o Shared mealtime with staff (Charras) [69] |
Improve hydration | o No particularly useful interventions were noted, but cervical spine manipulation appeared to increase dysphagia limit for those with swallowing problems (Bautmans) [56] |
Support meaningful engagement with food and/or drink | o Eating with carers (Charras) [69]o Family style meals for people with dementia, enhanced further by staff training (Altus) [68]o Facilitated breakfast club with supported involvement in preparing, conversing, eating and clearing up (Santo Pietro) [71] |
Improve quality of life | o Reminiscence cooking sessions (Huang 2009) [70] |
Support eating independence | o No particularly useful interventions assessed |
Improve quantity, quality or adequacy of food or fluid intake | o Combination of ONS, gratin diet, exercise and oral care (Beck) [32]o Finger food provision (Soltesz) [60]o High carbohydrate dinners (Young) [62]o Meal time or between meal feeding assistance, or individual mealtime assistance (Simmons 2008, Wong 2008) [66, 67]o Dysphagia diet (reformed minced and pureed foods and thickened fluids) for those with swallowing problems (Germain) [57] |